Primary care advocates cheer gains in 2027 MPFS but push CMS and private payers for more

Federal health officials are proposing to pay primary care physicians twice as much for coordinating patients' care when they do so inside an accountable care organization (ACO).

It would be the first time Medicare has varied a fee schedule payment based solely on ACO participation. The proposal arrives alongside a two-year strategy to address what officials described as the systemic undervaluation of primary care and behavioral health in Medicare's physician payment system, along with a roughly 30-page request for public comment on how to further revalue those services.

The Primary Care Collaborative (PCC) hosted “Primary Care Wins in the 2027 MPFS,” an online webinar devoted to the proposed 2027 Medicare Physician Fee Schedule (MPFS). PCC President and CEO talked through the rule's primary care provisions with Jake Quinton, M.D., chief medical officer for Medicare Parts A and B at the Centers for Medicare & Medicaid Services (CMS). A second panel, also moderated by Greiner, brought in Aisha Pittman, M.P.H., senior vice president of government affairs at the National Association of ACOs (NAACOS); Stephanie Quinn, senior vice president of external affairs and practice experience at the American Academy of Family Physicians (AAFP); and Nima Sheth, M.D., vice president of health justice at the National Partnership for Women & Families.

Doubling pay inside ACOs

The centerpiece of Quinton's presentation was a proposed change to billing code G2211, an add-on code Medicare created to pay for the complexity of serving as a patient's longitudinal primary care point of contact. Under the proposed rule, the code would be split into two tiers, with clinicians in ACOs paid roughly double the rate of those outside one.

CMS also proposed converting G2211 from a flat visit fee into a percentage of the underlying evaluation and management (E/M) visit code billed alongside it. Quinton estimated that change alone would translate into a 16% payment increase for clinicians outside an ACO and a 32% increase for those inside one.

About 75% of primary care physicians already participate in an ACO, an arrangement in which groups of clinicians share financial responsibility for the cost and quality of a patient population's care, Quinton said. CMS wants that share to grow.

Chasing pricing distortions

CMS is also asking the public to help identify where the fee schedule has become distorted. Quinton pointed to an example from Maryland's all-payer claims database.

"More than 500 times in our home state of Maryland, that service was conducted so frequently and billed for so frequently that the actual time that was estimated to be spent was more than 24 hours in a day," Quinton said, describing a pathology code for a tissue-exam that would not be expected to happen too frequently.

That finding helped prompt a request for information on revaluing primary care broadly, from visit levels to care management codes to how technology should factor into payment, Quinton said.

Smoothing the ACO on-ramp

Even with new incentives, CMS acknowledged that starting or joining an ACO remains a heavy lift for independent practices that lack the capital, technology or legal support. The agency proposed simplifying ACO participation and reducing quality-reporting burdens for practices working across different electronic medical records.

The proposed rule also includes an overall conversion factor decrease of about 1% for 2027, after a temporary 2.5% statutory pay increase for physicians expired, Quinton said.

Behavioral health boost

CMS proposed some of the largest payment increases in this year's rule for behavioral health services, tying the investment to the U.S. Department of Health and Human Services' (HHS) "Make America Healthy Again" initiative on evidence-based lifestyle change.

Tobacco and substance use cessation services, including screening, brief intervention and referral to treatment, would see about a 20% payment increase. The collaborative care model, an integrated behavioral health approach developed at the University of Washington, would see increases of 20% to 40%, Quinton said.

The rule would also create payment for group medical visits and health coaching services for the first time, and formally recognize shared medical appointments, changes Quinton said reflect growing evidence from the lifestyle medicine community.

AI enters the equation

Quinton also addressed how artificial intelligence tools, from ambient documentation software to clinical decision support platforms, are reshaping primary care practice and, potentially how CMS values it.

Quinton also sees patients at a federally qualified health center in Maryland and said he uses such tools regularly and finds them transformative for reducing documentation burden. But he said patients arriving with information from chatbots or web searches will not diminish the need for primary care physicians.

"It's certainly not going to replace primary care docs," Quinton said.

How AI should factor into fee schedule valuation is one of the questions CMS is asking about in this year's request for information, he said.

Maternity codes, Medicaid effects

The proposed rule would also unbundle maternity care codes, separating payment for prenatal, delivery and postpartum services long paid as a single package. Quinton said the change aligns with American Medical Association recommendations and is meant to help address the country's maternal mortality crisis.

The federal program staff acknowledge Medicare covers few births. But because state Medicaid programs and commercial insurers frequently base rates on Medicare's fee schedule, CMS's changes ripple beyond the Medicare population, Quinton said. Greiner noted PCC pushed for additional pediatric code updates this year that were not included, and she said that advocacy would continue.

APCM's rocky rollout

Quinton and the panel spent significant time on the advanced primary care management (APCM) code, created to pay for ongoing, between-visit care coordination. Uptake has lagged, which Quinton attributed partly to beneficiary cost sharing and partly to confusion over which services must be delivered each month to bill the code.

CMS is not proposing new cost-sharing changes to APCM this year, prioritizing cost-sharing waivers within ACOs instead, which its legal team identified as the most direct near-term path because of existing safe harbor protections, Quinton said. Clarifying and simplifying APCM and other care management codes is a focus of next year's rulemaking, he said.

Reining in remote monitoring, surgery spending

CMS also proposed tightening payment for remote physiologic and therapeutic monitoring after what Quinton described as “an explosion” in billing for those services, which the agency is watching for fraud, waste and abuse. The rule would require those services to be integrated within a clinical team.

Separately, CMS proposed cutting payment in half for evaluation and management visits billed the same day as minor procedures already bundled into a zero-day global payment, applying its existing multiple procedure payment reduction policy. Quinton said the change reflects concern that Medicare may be paying twice for overlapping time and resources. He predicted this change “is going to be a topic of considerable attention,” but that “Medicare really needs to know what we're getting, what we're paying for.”

Panel: Thank you, and can we have more?

The panel that followed, moderated by Greiner, welcomed the proposed changes while pressing for more.

Sheth, a psychiatrist, said the proposed behavioral health increases and cost-sharing waivers stood out, particularly for the estimated 34 million women among Medicare's more than 66 million beneficiaries. She cited research showing that one in five beneficiaries delay or skip needed care because of cost, and one in six beneficiaries over 65 report trouble paying medical bills.

Quinn said Medicare cannot fix primary care payment alone. Priority "1-A is greater investment in primary care," she said, adding that private payers need to follow Medicare's lead on codes like G2211 and APCM for the investment to reach practices broadly.

“CMS has really kind of gone up to the line in a lot of ways to invest in primary care, but if we don't really infuse the infrastructure with more investment, then we're just entrenching ourselves further in in the system,” she said.

Pittman pointed to the proposed cost-sharing waivers for ACOs as a major step.

"The beneficiary cost sharing waiver is huge," she said.

What do ACOs still need?

Pittman said NAACOS has pushed the administration to modernize ACOs in three areas: sustainability, burden reduction, and innovation.

She elaborated on sustainability, because long-tenured ACOs increasingly compete against their own past savings, reducing their ability to earn shared savings and reinvest in primary care.

"Shared savings has been one of the few ways to increase investments into primary care over the past decade, and it's been really successful," Pittman said.

As for innovation, Pittman cited the cost-sharing waivers and new capitation options tested in CMS models such as ACO REACH and the upcoming ACO LEAD model, for Long-term Enhanced ACO Design. She said those should become permanent, flexible options in the shared savings program.

How do we build the best care teams?

The panel also highlighted a proposed "primary care exception" letting medical residents see higher-complexity E/M visits without direct supervision. Quinn said the current rule does not reflect what residents will actually see in practice and creates unnecessary workflow strain on supervising faculty. Sheth agreed, citing her own experience working in a federally qualified health center.

Panelists were more measured about Medicare rule effects on community health workers and peer support specialists. Quinton said Medicare created two behavioral health integration codes in 2024 that peer support specialists can bill under. Bringing community health workers to people can be more effective for patients than being in a clinical setting, Sheth said. But she and Quinton agreed broader use of community health workers remains limited by training, workflow and interoperability gaps, not payment alone.

Quinn said data systems used by allied health professionals often do not connect with practices' other records, undercutting new payment policies. Sheth said the models still need clearer accountability standards to ensure new flexibility translates into results.

"We're just short on that accountability piece," Sheth said.

Who should bill G2211?

One recurring question was whether G2211 is reaching the right clinicians. The code has often been billed as frequently, or more frequently, by subspecialists as by primary care physicians, Greiner said.

Quinton said that's not necessarily a problem. Nephrologists managing dialysis patients and cardiologists who serve as some patients' primary point of contact can appropriately bill the code, he said. But CMS is asking whether clinicians who bill G2211 for a serious condition should also be responsible for a patient's broader preventive care needs.

"There's certainly a propensity for urologists to be billing the service," Quinton said, adding that CMS wants to ensure those clinicians are also addressing patients' broader preventive and lifestyle-related health needs.

Does primary care need separate fee schedule?

Asked whether primary care should get its own fee schedule separate from Medicare's budget-neutral system, Quinton said that decision rests with Congress. Anesthesiology and radiology already have special statutory treatment, he said. But primary care's broad, high-volume use makes it a poor fit for the budget-neutrality exemptions typically reserved for smaller, less common services.

Quinn pointed to a recent bill introduced by physicians in Congress as a sign of movement on the underlying problem: budget neutrality, which requires increases in one part of the fee schedule to be offset by cuts elsewhere. The legislation would address that, among other things such as basing physician payment on the Medicare Economic Index.

"Budget neutrality has been terrible for getting needed investment in primary care," Quinn said.

Paying for health, or not?

Greiner closed the webinar by calling the proposed rule a hopeful, if incomplete, step. PCC and the other organizations on the panel plan to submit formal comments on the rule and its requests for information, she said. They also will keep pressing CMS and private insurers to increase primary care investment beyond current levels, which Greiner said remain under five cents of every health care dollar spent.

"Is our payment system delivering health? We're not getting healthier as a population, and there are many reasons for that," Greiner said during the discussion. "It's not just the payment system, but I think that that is a contributor, and we need to think about how we change that payment system."